Provider Demographics
NPI:1376239673
Name:BLY, KAITLYN J
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:J
Last Name:BLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2873 EXECUTIVE PARK DR
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33331-3603
Mailing Address - Country:US
Mailing Address - Phone:754-812-8700
Mailing Address - Fax:
Practice Address - Street 1:2873 EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-3603
Practice Address - Country:US
Practice Address - Phone:754-812-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician